Background: People with advanced heart failure have repeated hospital admissions. Advance care planning can support patient preferences, but studies in people with heart failure have not been assessed. Aim: To evaluate the literature regarding advance care planning in heart failure. Design: Systematic review and narrative analysis (PROSPERO CRD42017059190). Data sources: Electronic databases were searched (1990 to 23 March 2017): MEDLINE(R), Cochrane Library, CINAHL and Scopus. Four journals were hand searched. Two independent researchers screened against eligibility criteria. One reviewer extracted all data and a sample by a second. Quality was assessed by Cochrane Risk of Bias or the Critical Appraisal Skills Programme Tool for Cohort Studies. Results: Out of the 1713 articles, 8 were included representing 14,357 participants from in/outpatient settings from five countries. Two randomised controlled trials and one observational study assessed planning as part of a specialist palliative care intervention; one randomised controlled trial assessed planning in addition to usual cardiology care; one randomised controlled trial and one observational study assessed planning in an integrated cardiology-palliative care model; one observational study assessed evidence of planning (advance directive) as part of usual care and one observational study was a secondary analysis of trial participants coded Do Not Attempt Cardiopulmonary Resuscitation. Advance care planning: (1) reduced hospitalisation (5/7 studies); (2) increased referral/use of palliative services (4/4 studies); and (3) supported deaths in the patient-preferred place (2/2 studies). Conclusion: Advance care planning as part of specialist palliative care reduces hospitalisation. Preliminary studies of planning integrated into generic care, accessing specialist palliative care support if needed, are promising.

Background:The effectiveness of cardiology-led palliative care is unknown; we have insufficient information to conduct a full trial.Aim:To assess the feasibility (recruitment/retention, data quality, variability/sample size estimation, safety) of a clinical trial of palliative cardiology effectiveness.Design:Non-randomised feasibility.Setting/participants:Unmatched symptomatic heart failure patients on optimal cardiac treatment from (1) cardiology-led palliative service (caring together group) and (2) heart failure liaison service (usual care group).Outcomes/safety:Symptoms (Edmonton Symptom Assessment Scale), Kansas City Cardiomyopathy Questionnaire, performance, understanding of disease, anticipatory care planning, cost-effectiveness, survival and carer burden.Results:A total of 77 participants (caring together group = 43; usual care group = 34) were enrolled (53% men; mean age 77 years (33–100)). The caring together group scored worse in Edmonton Symptom Assessment Scale (43.5 vs 35.2) and Kansas City Cardiomyopathy Questionnaire (35.4 vs 39.9). The caring together group had a lower consent/screen ratio (1:1.7 vs 1: 2.8) and few died before approach (0.08% vs 16%) or declined invitation (17% vs 37%).Data quality:At 4 months, 74% in the caring together group and 71% in the usual care group provided data. Most attrition was due to death or deterioration. Data quality in self-report measures was otherwise good.Safety:There was no difference in survival. Symptoms and quality of life improved in both groups. A future trial requires 141 (202 allowing 30% attrition) to detect a minimal clinical difference (1 point) in Edmonton Symptom Assessment Scale score for breathlessness (80% power). More participants (176; 252 allowing 30% attrition) are needed to detect a 10.5 change in Kansas City Cardiomyopathy Questionnaire score (80% power; minimum clinical difference = 5).Conclusion:A trial to test the clinical effectiveness (improvement in breathlessness) of cardiology-led palliative care is feasible.